Lane County Hospital - Application for Employment

PLEASE FILL IN AS MANY SPACES AS POSSIBLE

Last Name   First Name     MI

Address City   State    Zip   Phone   e-mail

Position Desired  

Current Employer  

Reason for leaving current job

What prompted you to apply here?

Training for the position desired.

Other training or experience.

Are you related to anyone in our employ? yes no

If yes, to whom and how. 

List any physical disabilities or limitations that may influence your ability to do the job applied for.

Have you ever been convicted of a crime against a person? yes no

If yes, explain:

Professional License Number State of licensure

In case of Emergency Notify:

Name: Relationship

Address: Phone

EDUCATION

Name of school/college Location

Major Area of Study/Subject Graduate? yes no / /  Degree: yes no

Years attended:      From: To:

Name of school/college Location

Major Area of Study/Subject Graduate? yes no / /  Degree: yes no

Years attended:      From: To:

Name of school/college Location

Major Area of Study/Subject Graduate? yes no / /  Degree: yes no

Years attended:      From: To:

Past Employers (List in order from most recent to oldest)

Name: Address:

Contact Person: Phone:

Name: Address:

Contact Person: Phone:

Name: Address:

Contact Person: Phone:

Personal References (Not Relatives)

Name: Address: Phone:
Name: Address: Phone:
Name: Address: Phone:

EMPLOYMENT UNDERSTANDING

This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, age, or physical or mental disability unrelated to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

I voluntarily give this institution the right to make a thorough investigation of my past employment and activities (including a criminal background check), and I agree to cooperate in such investigations and release from liability or responsibility all persons, companies or corporations supplying such information.

Yes  No  In lieu of a signature  enter last four digits of your social security number  

I consent to take a physical examination, and such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent upon passing the physical examination which relates to the essential duties I would be required to perform.

I understand that my employment is at will, and either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

If employed, I will be required to complete an Employment Verification Form (I-9), and within three (3) days show satisfactory evidence of identity and eligibility for employment,

I also agree if employed, to serve to the beast of my ability and to abide by the policies established by Lane County Hospital and to abide by any future policies that may be established.

In lieu of a signature  enter last four digits of your social security number   Date: